Visualising the heart with Dr Sanjay Gupta

In episode #42, Paul talks with consultant cardiologist Dr Sanjay Gupta on a subject that he specialises in, cardiac imaging.

Blog | Dr Sanjay Gupta Cardiologist

Dr Gupta takes us through the various tools that he uses such as echocardiograms, computerised tomography (CT) scanning and Magnetic Resonance Imaging (MRI) scanning.

Dr Gupta explains everything about these techniques that patients need to know and also talks about how future tools may help prevent the main cause of sudden cardiac deaths – heart attacks.

Available to listen on the link below or Spotify, Apple , Google, YouTube and your favourite podcast player.

#042 Visualising the heart with Dr Sanjay Gupta

Paul Swindell: [00:00:00] Hello and welcome to another episode of the life after cardiac arrest podcast with me, your host, Paul Swindell.

And today I'm joined by Dr Sanjay Gupta, who is a consultant cardiologist at York teaching hospital, in the North of England. He also is a very popular on social media and you'll have seen him possibly doing, YouTube videos and Facebook videos on all sorts of cardiac related matters and he has a specialist interest in cardiac imaging, which we will be talking about today.

. So, welcome Dr Gupta and nice to speak with you again.

Dr Sanjay Gupta: [00:00:46] Thank you so much for having me.

Paul Swindell: [00:00:48] So cardiac imaging.

So what are we talking about there?

Dr Sanjay Gupta: [00:00:52] We're talking about, modalities which allow us to visualize the heart and the arteries surrounding the heart.

So visualizing the heart, both, to make a diagnosis, to tell you about the health of the heart, and to also guide you, about prognosis.

Paul Swindell: [00:01:14] So what are the, tools that you use?

What have you got in your toolbox ?

And, why would someone need to go through those processes that you do?

Dr Sanjay Gupta: [00:01:22] So, common modalities include echocardiography, ultrasound of the heart, CT scanning of the heart. MRI scanning of the heart, and also, radio nuclear imaging of the heart, so perfusion scanning, et cetera.

Okay, so the first thing to say is that by far and away the commonest and the most easily accessible tool we have this echocardiography.

One of the unique things about the heart is it's a moving structure and therefore, to try and understand it. you have to have moving images and that is different from say, imaging the liver or imaging the brain.

Echocardiography uses ultrasound waves, which bounce off different structures of the heart and produce a moving image on a screen.

It's very easily accessible, is available in every hospital and it offers a crude, but, well validated way to assess the structure of the heart. So, on echocardiography, you can see the heart, you can see the heart valves, you can see the size of the chambers of the heart.

You can work out whether there's any leaking of the valves, whether there's any tightness of the valves and you can see whether the function of the heart is strong or weak. And what we do know is from all the studies that if you have a structurally normal heart on the echocardiogram, then in general that points to an excellent prognosis and if you have damage to the heart or if the heart is weak on the echocardiogram, then that points your worst prognosis.

Paul Swindell: [00:03:01] And the echocardiogram, am I right in thinking these are similar tools to what the you use on a pregnant lady to look at the fetus

Dr Sanjay Gupta: [00:03:09] Absolutely, exactly the same.

Paul Swindell: [00:03:12] So that's a noninvasive procedure and you just typically put some gel on someone don't you?

Dr Sanjay Gupta: [00:03:17] You, put some jelly on the, on the patient, and then, you have this transducer and the transducer will emit, sound waves and the sound waves will hit different structures and bounce back.

And that will create an image on the screen, it can also, it is also useful in terms of working out which way blood is flowing. So, for example, if you close your eyes, you can tell usually whether an ambulance is coming towards you or going away. This is the Doppler principle. And so if you can use that information and convert it into a colour signal, you can then see where the blood is coming towards you or going away.

And that then tells you whether valves are leaky or functioning normally.

Paul Swindell: [00:04:03] Oh okay. I see. That's clever.

So you said that it's quite accurate at determining whether someone's got a functionally correct heart?

Dr Sanjay Gupta: [00:04:11] Yeah, I mean, I think it's a, I think it's still a crude test, but, there's two things.

One, it's well validated.

A lot of all the major research studies have shown that actually, you know, the information it gives, does, point towards prognosis. It's the gold standard in terms of trying to make a diagnosis of something like heart failure where the heart is weak or not.

All valvular problems, the echocardiogram is a very good way of determining, the nature of the problem, the severity of problem, and may also help you work out the best treatment for the problem.

Paul Swindell: [00:04:47] And presumably before that you would have done a, I know it's not, an imaging test, but a 12 lead ECG.

Dr Sanjay Gupta: [00:04:55] Yeah, so the 12 lead ECG is telling you something different, right?

12 lead ECG is just telling you about the electricity through the heart. So it is just telling you, about the electricity and you are making assumptions based on those electrical patterns.

With an echocardiogram you're actually looking at the heart.

So with a 12 lead ECG, if you had a valve and your valve was, let's say, very narrowed, that would cause the heart to become more muscular because it would have to generate more force against that narrowed valve. The heart would become more muscular, which means the electricity would have to go through a thicker heart muscle, and you would get much bigger complexes on the ECG.

So if you saw bigger complexes on the ECG, you would say, okay, that looks like it's a more muscular heart, which means that it could be due to this or that.

It didn't really give you the diagnosis, it just told you, but the heart had changed this way, based on the, electricity through the heart muscle.

With the echo, you're actually visualizing the heart.

So, a far better way, you're actually seeing, you can actually measure the thickness of the heart and you can look at the valves, et cetera.

So, yeah, in the old days, we didn't really have very much at all to determine what was going on, but, since echocardiography has come along and, now we have more complex echocardiographies. So previously we just used to have something called M mode echocardiography, then change it two dimensional echocardiography. Now we have three dimensional echocardiography.

So that has really revolutionized how we diagnose certain conditions, and how we monitor conditions, because it is accessible.

You know, the machines are not that expensive.

There's a lot of expertise on how to, you know, experienced staff, et cetera. It doesn't require, really, it doesn't require very, very highly specialized, just because it's so much more accessible. So, echocardiography is the kind of staple investigation.

And from my perspective, if the first test I would do, if I was worried about someone would be an echocardiogram.

If they have a strong heart, I feel relieved. If they have a weak heart, I get more worried.

Paul Swindell: [00:07:02] And so what would you progress to next if, the echocardiogram hasn't told you what you needed to know or shown that there's a problem there, but you need a little bit more detail, where would you go next?

Dr Sanjay Gupta: [00:07:14] The echocardiogram is like if you thought of the heart as a car. The echocardiography is looking at the engine of the car.

It doesn't tell you what the arteries that supply the blood to the heart look like. So with an echocardiogram, you can't see the heart arteries. You can't tell whether the heart arteries are narrowed or anything.

All you can tell is that there's been no damage to the heart.

So if you wanted to visualize the heart arteries then the next step would be to do something called cardiac CT, CT scanning, which has now become the gold standard for looking at heart arteries, you know, for the majority of patients with chest discomfort, and with cardiac CT, what you're doing is you're delineating the heart arteries themselves, and that will then tell you whether the heart arteries are narrowed or whether there are any blockages, et cetera.

Paul Swindell: [00:08:07] So , CT, what does that stand for?

And again, is this an invasive procedure ?

Dr Sanjay Gupta: [00:08:13] No, it's a noninvasive procedure and CT stands for computer tomogram or a cat scan. That's, you know, how people recognize it, but basically it involves going through a scanner. The is heart slowed down because again, the heart is a moving structure, and if you want to visualize the arteries, if you don't slow the heart down, then the arteries will move with the heart and you'll get blurred images.

So what they try and do is they slow the heart down.

And therefore in that short period of time when the heart is very slow, they're trying to image these arteries. The arteries are imaged by giving the person a contrast through one of their veins, contrast agent. And that contrast agent goes through the vessels and you can then take pictures of the heart arteries.

Paul Swindell: [00:09:00] Okay, sounds like, is it a little bit more expensive piece of equipment?

Dr Sanjay Gupta: [00:09:04] Definitely, not all centers have access to cardiac CT.

Currently the guidance says that if you, for example, came and said to me, look, I'm getting chest pain. And I'm like, you know, I would say, well, I'm not quite sure.

Maybe it could be your heart.

Maybe it couldn't be.

Maybe it isn't your heart.

What tests should we do?

The current guidance is that the majority of those patients should have a cardiac CT. And a cardiac CT is an exceptionally good test in terms of if your heart arteries are normal, it's probably the best test we have out there that tells us that if your heart arteries looked normal in the cardiac CT, then the chances of something bad happening to you are really, really low.

It's not so good if you have abnormalities because you still then need to image it further. Because what tends to happen is a lot of times when you get buildup of plaque and disease in the, in the blood vessels, you get deposition of calcium and calcium reflects rays.

So what, what then happens is, you know, when you're doing the cardiac CT, you get these bright bits of calcium and you can't see beyond them because of the calcium.

So when you see a lot of kind of calcium in the heart arteries, one, it tells you that the arteries are diseased, but then you have to do a better test or a more invasive test to see exactly how bad the narrowings are beyond those lumps of calcium, which are in some way blurring the image because they're reflecting these.

It's like taking a flash photograph in front of a mirror. You get a, you know, you get that bright light hitting you back. and so, in that setting, if, if you have an abnormal cardiac CT, most people would then go on and do something called an invasive angiogram.

Which actually involves putting a needle into either the groin or the the wrist and passing a tube all the way to the heart, and then squirting some dye into that tube that dye that fills up the heart arteries and then you take x-rays.

That way you're purely looking at the heart arteries that actually lumen of the heart arteries, and that is the gold standard kind of invasive test for coronary disease.

Paul Swindell: [00:11:16] So with the CT and the angiogram, you're not actually looking at the heart, you're just looking at the

Dr Sanjay Gupta: [00:11:22] Artery

Paul Swindell: [00:11:22] Arteries around it.

Dr Sanjay Gupta: [00:11:23] Yeah, exactly, exactly.

Paul Swindell: [00:11:25] Okay.

Dr Sanjay Gupta: [00:11:26] If we wanted the heart and more details, so you know where you have the echocardiogram, is there another test which can offer you the same thing but in a lot more detail?

And the answer is yes.

That's where you go to cardiac, magnetic resonance imaging, cardiac MRI.

Cardiac MRI, allows a much better visualization of the heart, but obviously it's a much more sophisticated procedure, it involves the patients having to go in this very claustrophobic tunnel for about an hour with lots of noise and clanging, but it is a test which allows excellent visualization of the heart.

One other thing which is really useful for you to know, I guess, is that, there was a series of experiments. Done in America where they took a bunch of dogs and they occluded the heart arteries and they studied the damage that was done to the heart when they occluded the heart arteries.

When you create a heart attack, what is the pattern of the damage that occurs in the heart?

And what they found is that all damage caused by heart attacks goes from inwards, outwards, so from within the heart, outwards. The inner most layer is always affected first.

With cardiac magnetic resonance, you can give a dye called gadolinium and that can delineate scar that accumulates in scar. And so if you then take the images and you find that that scar is involving the inner most layer, then you make a good assumption that that scar was caused by a heart attack. So in that sense with an echocardiogram, all you see is a bit that's not moving and you assume that there's been damage.

But what we don't know for sure, and sometimes we cannot be sure is was that because the person that had a heart attack was that because the person had a virus? Was that because of something else?

And MRI is very good because it delineates exactly the nature of the damage and the pattern of the damage by gives you a good clue as to why that may have happened in the first place.

Paul Swindell: [00:13:27] Can you do a, an MRI or a moving MRI of the heart? Like you, like you said, the echo-cardiogram, you can see the blood moving and whether it's going in the right direction, what have you, do you get that similar sort of picture from the MRI.

Dr Sanjay Gupta: [00:13:43] Yeah again, with an MRI you get, you can get moving images and, so you can see the function of the heart, you can see the function of the heart better than with echocardiography. It's not so good for looking at the way blood moves in and out in the valves, et cetera. But people are developing a MRI and you know it's coming along, but in that sense, echocardiography is probably still better to look at the heart valves and you know, the, the actual physiology to study physiological changes within the heart I think echocardiography is still better.

But echocardiography has a problem, you know, not everyone has the best pictures. You know, you have to get a window and some people carry extra weight or who have ribs very close together. You may not necessarily get any kind of decent pictures to be able to make, any kind of assessment of their hearts.

MRI doesn't have those constraints.

So with MRI, you're not so worried, you can still visualize the heart very well.

Paul Swindell: [00:14:43] So it sounds like all of them have a part to play in your toolbox as it were. The they, they will show you something slightly different.

Dr Sanjay Gupta: [00:14:51] Absolutely. I mean, there are anatomical tests.

There are functional tests, there are tests for the heart arteries, and then there are tests with the actual heart itself, the heart muscle.

Paul Swindell: [00:15:02] So is there anything, anything else that you might do or this is something else that you'd like, that isn't invented yet?

Dr Sanjay Gupta: [00:15:10] So in the old days, what we used to think is if the heart looks okay on the heart scan, on an echocardiogram, then the person doesn't have heart failure, for example. You know the heart, if the heart looks okay on an echocardiogram, then it's not your heart. So someone comes in and says, oh, I'm getting more and more breathless, my legs are filling up with fluid. Those are typical signs of the heart being weak, but if you then did the echocardiogram and the found that the heart was strong, then most people would turn around at that point and say, no, that's not your heart.

Now they're beginning to realize that actually there are some people who have what may look like a normal heart on the scan, but may still have signs of heart failure. And actually when you follow these people up, they do badly in the long run anyway. And so we're beginning to realize that we've used a two dimensional modality to study a very complex three dimensional structure.

You know, the heart will move.

When the heart contracts, it contracts in different ways.

It contracts radially.

It contracts longetudinally it contracts, it twists and turns.

But the modalities we're using are only looking at one movement. And therefore, I think, we are beginning to realize that sometimes our tests have their own kind of limitations, but it is that recognition which will allow us to move forward and identify new modalities, which will help us determine, what's going on with the heart.

The other thing of course, to say is that most of these are a visual impression. You know, you're just looking at the heart, right?

You haven't gone inside the heart. You haven't studied in under a microscope.

So can the heart still be diseased if it looks normal?

And the answer is yes, it can still be diseased, even if it looks normal.

This is the fundamental problem when we hear about people like, athletes you know, who are playing football and then suddenly dropped down, dead on the pitch.

I mean, these guys have been investigated, they've gone through medical screening, I'm sure they've come through a whole manner of tests. And so it is always sort of something that is very worrying when someone like that suddenly drops down dead because you say, well, he had all the tests, they were all normal, why did this happen?

And the answer is because we are only basing our assessments on a visual interpretation. We haven't actually taken the heart, looked at it under a microscope. We don't know. You know, we can only look for things that are causing an outward change in appearance.

Paul Swindell: [00:17:42] I guess the heart isn't an under stress as well when you're doing these tests either.

Dr Sanjay Gupta: [00:17:47] We do something called stress echocardiography, so where you can actually look at the heart and then you put the person on a treadmill and make the heart beat really, really fast, and then you bring them off and study the heart again, and that's a good way of assessing, well, the strength of the heart.

And those aren't, those aren't, you know, those are relatively straightforward. It is that kind of patient like yourself, you know, when you mentioned that looking at out of the blue, suddenly, you know, one day you're out.

Why did that happen?

What was there anything that could have determined that that was going to happen beforehand?

And the reality is probably not.

And those are the groups of patients we need to study better and we need to develop more, advanced, modalities, which allow us to determine, you know, determine risk. I think, I think what we have is a good tools, for a population to study a population.

Are we very good at using those tools to study an individual? And that's a bit more difficult, you know, because the reality is anyone anywhere can have something bad happens to the many ones suffer cardiac arrest at any point.

What we are doing is we're saying, okay, well if you've got a strong looking heart, then you in general belong to that population is going to do well.

Paul Swindell: [00:19:00] And so you talked about these other modalities , do you know of any technologies that are coming along?

Dr Sanjay Gupta: [00:19:05] I think there'll be metabolic imaging is a very interesting field.

So one of the very interesting things that the big problem by far as heart attacks, that is the, by far the biggest killer, right? So sudden heart attacks, heart attacks, which come out of the blue, they, they're responsible for the majority of sudden deaths.

And, the, the question is why two heart attacks occur?

And, you know, the general kind of understanding certainly amongst the public is that you get narrowing. So if your heart arteries, the heart arteries get narrower and narrower and one day one blocks off and that causes the heart not to get the blood, it gets damaged.

The heart misbehaves because it's not getting any blood and the person drops down dead. The reality is. when you look at the, or, our understanding has changed because what we're starting to realize this, not all people who have significant narrowings are going die because that narrowing has blocked off.

Sometimes people don't have significant narrowings. They have a may have a very, very minor narrowing and one day, for whatever reason, that particular area, that little clot breaks off. And the body thinks you've sustained a wound and forms a blood clot to try and heal that wound and the blood clot inadvertently blocks of the vessel and stops the blood getting to the heart, which causes the heart attack.

And that can occur within a matter of two or three minutes.

Paul Swindell: [00:20:29] Oh wow. I didn't realize it was that quick.

Dr Sanjay Gupta: [00:20:31] Yeah. So those are the people. You see that there are two groups of people. There'll be those people who will say, I've been getting chest pain every time I walk, I walk. So I went to see my doctor. My doctor did a test.

He said, I have 99% blockage in, says I need an emergency bypass. Thank God I have the bypass. It saved my life. The reality is actually when you look at all the data, bypasses and stents done in that kind of non-acute setting have not been shown to prolong life. So the question is why have they not been shown to prolong life.

And the answer is because that narrowing was probably not the narrowing that was going to kill that patient. The patients, a lot of patients die because they get unstable clot, which may not be causing a narrow, and that unstable clot chooses to break off. If you think about it, you get cold clots, which are nice sort of clots, which have been there for a long time.

They're like, cement. They're not, they're not fragile, they don't break off. And then you have hot plaque, which is a lot more, a lot more fragile, a lot more inflamed, and one chooses to break off. And that's where you get that sudden, the patient who is completely fine and boom, dead. so when you image the heart at the moment, anatomical imaging is only largely geared towards trying to identify the narrowest bits.

It doesn't identify the bits that are most likely to break off.

So if in some way you can develop techniques which identify which plaques are hot and which plaques are cold, then you can start treating hot plaques. And if you treated hot plaques may be the risk of sudden death from heart attacks will go less.

Paul Swindell: [00:22:15] I see. That sounds good.

Is that feasible, do you think?

Dr Sanjay Gupta: [00:22:19] I think so. I think because, I think there's, you know, the, the hot plaque tend to be more inflamed. They tend to be newer. So the process is going on with a hot plaque are a different, I think there are centers, there's a center in Oxford that has an interest in this, so I think that would be a really interesting thing.

The problem at the moment is, you know, stents and bypasses are only done for the narrow bits. Right? Because if you, if you don't have a narrowing, then if you bypass the narrowing, there's no reason the blood will go down the bypass because there's no real narrowing. So the blood will choose to go down where it's always gone down and the bypass would fail.

Similarly, if you stent something which is not narrowed, you don't derive any benefit.

So, of course, it'd be one thing to try and identify hot plugs and then it would be another thing to try and say, well, how would you go about treating these hot plugs?

How would you make these hot plugs colder?

And I think that would be a very interesting field.

Paul Swindell: [00:23:15] Topic for another podcast, I think.

Well, I think there's a topic for a lot of researchers and probably a lot of money as well.

Dr Sanjay Gupta: [00:23:23] I think it's a very interesting field. I think that's, I think is the most important thing that's come out in my understanding of cardiology, which is, you know, the bits that we think are the most threatening tend, you know, the people die of things, which can actually look relatively innocuous, but then choose to misbehave rather than something that looks ugly.

Because it's, long standing things are unlikely just to suddenly cause a problem, whereas something that is relatively acute, something which is very hot, as much more likely to be dangerous.

Paul Swindell: [00:23:56] Okay.

Have you got anything else to add in this imaging arena?

Anything you'd like to impart, or have we said it all basically?

Dr Sanjay Gupta: [00:24:06] I think we've said it all, no, I think we've said it all.

I can't think of anything else.

Paul Swindell: [00:24:10] So in general, cardiac imaging patients should never be really worried about them cause they're either noninvasive or minimally invasive.

You might have to have an injection or something like that.

Dr Sanjay Gupta: [00:24:23] Yeah. I think this is the real advantage with noninvasive modalities because, you know, they offer a high yield, low risk and the invasive ones are generally only done when the patient really, really needs them now, not an ad hoc so to speak.

So there's a lot to be said. I mean, we've moved, you know, as cardiac CT is incredible. It's to be able to visualize the heart arteries in this way, and to have a test which has been shown that if it's normal, it portends to really good patient outcomes is really reassuring.

Paul Swindell: [00:24:55] Well. That's brilliant.

Thank you very much, Dr Gupta for that really interesting overview of all of the types of imaging that patients might expect to encounter if there are ever become a cardiac patient.

And thank you very much again for your time. It's been really enjoyable.

Thanks a lot.

Dr Sanjay Gupta: [00:25:15] Thank you so much. I've enjoyed it.

Paul Swindell: [00:25:19] This concludes this episode of the life After Cardiac Arrest podcast, and I'd love to know what you think. And you can do that via Facebook, Twitter, Instagram, or the website, and you can find this by Googling Sudden Cardiac Arrest UK or the Life after cardiac arrest podcast.

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And I'll speak to you next time.

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Presented and edited by Paul Swindell.

Recorded March 2020. 

Question time #1 with Dr Tom Keeble

In episode #40, in the second part of his conversation with Paul talks with LACA regular consultant cardiologist Dr Tom Keeble.

Dr Keeble answers cardiology questions that have been put to him by members of Sudden Cardiac Arrest UK. These include the subjects of beta-blockers, electrolytes such as potassium and magnesium, atherosclerosis (furring of the arteries) and future risk, anti-platelet therapy, super-asperin, ectopics, ICD’s (implant healing and leads).

Available to listen on the link below or Spotify, Apple , Google, YouTube and your favourite podcast player.

#040 Question Time #1 with Dr Tom Keeble

Paul Swindell: Hello and welcome to another episode of the Life After Cardiac Arrest podcast with me, your host, Paul Swindell. I'm joined today by Dr Tom Keeble, who's here to answer some of your questions that we've had in the group.

So welcome, Tom, and welcome on this beautiful sunny morning.

Dr Tom Keeble: Yeah,

Good morning.

Paul Swindell: We're going to jump straight in because we've already been chatting about Covid 19 but we're going to go onto subjects that aren't related to that cause we tackled most of those questions in the previous episode. So, the first question is, why are beta blockers prescribed after a sudden cardiac arrest that was triggered by an exercise induced oxygen demand ischemia. If the original cause has been rectified by surgery and they had a bypass and they've got ongoing management with statins, diet and exercise. So, it's always the, the beta blocker question

Dr Tom Keeble: So, look. I, a very medically asked question.

So, the bottom line is, beta blockers are a good drug. A lot of patients don't like beta blockers if they have side effects. And I can understand, you know, if you feel tired, if you have bad dreams, if you have, any of the other side effects of dizziness or anything else that you don't like, but the bottom line is, is that had I had a cardiac arrest, whether it's a VF or a VT, a an arrhythmic arrest that needed defibrillation, the best drug on the planet to take is essentially a beta blocker, and the beta blocker is excellent for a variety of reasons. First of all, from the question, the way in which the question was worded,

Number one, it reduces your hearts oxygen demand all of the time because it lowers the heart rate.

Number two, it makes your heart more efficient.

Number three, lowers your blood pressure a bit, which in most patients with cardiovascular disease is what is required.

It also makes the heart pump better. It reduces arrhythmia's, and we know from long term studies, in randomized studies, it prevents cardiovascular death.

So, if you're a patient who's already had essentially an aborted cardiac death from having a cardiac arrest and being resuscitated, it's kind of hard from a medical standpoint, from all of the reasons that I've just stated. Why you wouldn't want to be on a beta blocker.

For me, that would be the tablet that if I wasn't on, I'd be asking, why am I not on it?

Now, as I say, we understand many people may be allergic, people might have terrible asthma and can't take it. That's very rare. and of course. If the side effects are so overwhelming that they outweigh any benefits to you, then of course you wouldn't want to take them.

But most patients tolerate beta blockers well. And I think the other thing is that a lot of the side effects of beta blockers that people would describe are tiredness. Now we know that your group of patients post cardiac arrest and brain injured patients have a huge amount of tiredness and fatigue anyways, it's the number ep symptom that cardiac arrest patients describe, so to put it down to your beta blocker is probably unfair.

So, I think we have to take every patient on a case to case basis. Beta blockers are not good for everybody. That's not what I'm saying, but in the vast majority of cardiovascular induced, and what I mean by that is furred arteries and heart attack induced cardiac arrests. Beta blockers are a good drug and should at least be trialed and should at least be given time to have a chance of getting used to them. But if the side effects are completely untoward and that the patient can not tolerate them, then of course in line with your physician, your cardiologist, they should be considered for a, a different tablet.

Paul Swindell: I mean, there are, there are many different types of beta blocker aren't there?

Dr Tom Keeble: That's true. To be fair, over the last five years, most people have come down to use pretty much one or two, and the most commonly used one, which has a very safe and a good side effect profile is Bisoprolol and the reason why that's good, it's a cardio specific beta blocker, which has particular benefits in heart failure patients, which again, if you've had a cardiac arrest and your heart pump is not completely normal, you will benefit from these cardiac specific ones.

And the ones that we use in those include Bisoprolol, Carvedilol, and Metoprolol. But by far the commonest used one is Bisoprolol. It's generally used once a day you can use it twice a day. I do sometimes, but it's generally used once a day and it's an incredibly good drug.

Paul Swindell: And following on from that, someone says they've got, DCM dilated cardiomyopathy and an SICD, and they've had a couple of, appropriate VF shocks and they've had a couple of, episodes of VF, which have been self-corrected, and they say, is there a link between taking my Bisoprolol at 8pm and my Ramipril and Eplerenone at 10-11 o'clock causing my VF? My heart rate usually sits between 40 to 60 BPM when asleep, but sometimes goes as low as the 30s.

Dr Tom Keeble: Sure. Well, I think it would be very interesting to know just in this personal case, when the cardiac arrests have occurred and the defibrillator has had to do its job, and I think what we do know with any drug is that even if you have a controlled release drug, you do not maintain exactly the same drug concentration over a 24 hour period.

And that we know that there's a sort of bell-shaped curve where you of course, absorb it. It has it sort of peak effect. And then even with slow release medicines, the concentration in your bloodstream, then weans off over the next few hours, then waiting for the next dose the next day, 24 hours later.

And I suppose what this draws into, into close point is that. We need to take our drugs regularly at the same time, at the same, on the same time every day, so that we can give our body the best chance of having a steady state. So, with regards to, to VF and VT. Ramipril and Eplerenone are both drugs to try and improve the heart function and keep the potassium normal.

So, I don't think it's likely that that are sort of a daily variation in their dose would have an effect on whether you would have a VF or VT. But of course, a beta blocker, as we talked about slightly earlier. It's a very powerful protective anti, arrhythmic medicine that if you either missed your dose or maybe you were at a low point in your dose curve and you did some exercise or some stress or something, then that could potentially give rise to it.

If people have a particular arrhythmia at a particular time, let's say at seven o'clock in the morning, the low point of your beta blocker dose because you take it at eight o'clock in the morning then sometimes we space out the beta blocker and give it half in the morning and half at night so that you have a slightly.

Smoother and sort of better profile throughout the 24 hour period. Of course. The other thing is you can consider other anti arrhythmic drugs under the watchful eye of your cardiologist or electrophysiology doctor to ensure you're on the best possible medicines to limit your exposure and limit what your subcutaneous ICD has to do.

Because. At the end of the day, we want the ICD, whether it's subcutaneous or a normal ICD to be your insurance policy, and we don't really want to use, if at all possible, we'd much rather we can control things. With medicines and then the ICD is there just to get you out of jail. If an arrhythmia occurs.

Paul Swindell: you touched on potassium there, someone, so on the third of the question, it's not on potassium. It's talking about magnesium levels and the hearing that magnesium levels are critical to a heart functioning correctly. And it's also read that. Magnesium levels are rarely tested, and they wonder why this is, especially in the cases that are idiopathic.

Dr Tom Keeble: Yeah. Good question. So, I think if any patient comes to the hospital with either cardiac arrest or arrhythmia that has hospitalized someone, that we always measure magnesium. So, magnesium, obviously is in our diet and that's where we predominantly get it from a lot of people are slightly magnesium deficient.

We see that in many patients who come through the door. And the good thing is it's very, very easy to remedy either at home with supplements or what we do in the hospital is we give a magnesium infusion, which we can get the magnesium to normal levels within about two hours. And so that can often help prevent any further arrhythmias.

The other important thing about magnesium is that it also helps reabsorb potassium. So, if you are really low in magnesium, you will often be really low in potassium too, depending on what other drugs you're on and what your dietary intake is like. And so that. Can also cause problems. So often we need to get the magnesium levels back to a normal state, which will then in time allow the potassium levels to come back to a normal level.

And the bottom line is, is that the body is very clever at controlling all of its salt levels and any significant deviation of a particular salt level, be it potassium, bit sodium, be it magnesium bit calcium can have detrimental effects upon your heart rhythm. but no, we definitely don't, monitor magnesium.

And if you like asymptomatic patients in the community that we, we, we've never done that. But if you have persistent arrhythmias, either at home or in hospital, then we would generally, measure it and replace it as we see fit.

Paul Swindell: the question asked about the fact that they are rarely tested it.

I did read somewhere that it's actually hard to do a, an easy test without being invasive, I. E. taking a blood sample or even. Is it in the bone marrow? Is that correct?

Dr Tom Keeble: No. So, it makes, magnesium is definitely from blood serum. You can do it. There is a point of care test. We have it in our catheter lab where you can take a finger prick sample and put it onto, yeah.

Into this point of care machine. And it will give you, you the magnesium, as a point of care. So, it is quite easily measured. You can do it with a, a, say a finger prick or more generally you would do it from a, a blood sample.

Paul Swindell: Do you know the home test kits? Do you know,

Dr Tom Keeble: I wouldn't bother with that to be perfectly Frank.

I think that, you know, I think again, you got to go back to simple things. If you're well and you have a balanced diet, the chances of you having a low magnesium and low potassium are, are low.

Does that make sense?

Paul Swindell: Okay. Yep.

Paul Swindell: and this goes back to the original question. It was sort of a

Paul Swindell: How does having a sudden cardiac arrest due to buildup of cholesterol, increase the risk of a future event if that is being managed.

Dr Tom Keeble: So, if you have a cardiac arrest secondary to a furring up of the arteries or atherosclerosis is the sort of terminology, then usually that is in the setting of a heart attack where you get a sudden occlusion of blood supply to your heart muscle and your heart muscle doesn't like it and goes into this fibrillating state where it sort of wobbles and then you pass out and have your cardiac arrest in the treatment, of course, is CPR recognition and defibrillation, hopefully in the community or if not in the hospital when the paramedics arrive.

What you have to remember with atherosclerosis or furring is it's a continuous process. The risk factors need to be controlled to prevent this from happening long term. So if you get a bypass or a stent, all that really does is sort out the acute problem, gets the blood supply fixed, quickly, but of course if you still have high blood pressure, high cholesterol, overweight, diabetes, and these are all badly controlled, then the furring�s will just come back within a year, six months, two years.

And so, once you've had these events caused by furring, it is absolutely vital that we focus on all of the risk factors to minimize the risks of that happening in the future again. And so really careful attention to cholesterol with statins, really careful attention of blood pressure with pills, really a careful attention of diabetes and weight loss and exercise regimes and all of these things together prevent you from having further events.

The stent is not the cure. All the stent or the bypass does is make the blood supply good at that moment in time. It does nothing to prevent the future events, which of course is the most important thing.

Paul Swindell: Okay. And it's sort of as, as you sort of touched on life lifestyle and diet and things like that, I guess a more and more important, obviously the fewer tablets you can be on, the better.

I would say, personally,

Dr Tom Keeble: I think that's wrong and it's not because I'm a prescribing doctor. I think the bottom line is you need the tablets that you need and everybody will be different. Patient A who's had a idiopathic cardiac arrest and has a defibrillator, may need no tablets or may just have a beta blocker.

It depends completely on the cause.

Depends completely on the risk of other things happening.

Depends completely on the risk factors if there's a coronary patient, but if you've got a patient who has a pump, which is not great, has a high cholesterol, has diabetes. You would, you just need to control all the risk factors.

And I don't mind if that's with tablets or if that's with lifestyle. So let me take diabetes for, for example, if you are a 60 year old male and you have a cardiac arrest because of a heart attack and you are overweight, let's say you're 16 stone and you have type two diabetes, there's really good evidence out there that if you slim down with exercise over time and in a sustainable way.

So say for instance, 12 stone, which may be is the right weight for that human being, then you're type two diabetes is highly likely to go away, I. E. your sugars would go back to a completely normal level because the fat, would you, it gives you insulin resistance and therefore you get type two diabetes.

So, we have to look at evidence too. So, every tablet that a patient is on post heart attack is not just to make us feel better. It's to reduce the risk of cardiovascular death, heart attack and stroke. And for each tablet that patients are on, be that aspirin, be that Ticagrelor, be that an ACE inhibitor, be that a beta blocker.

Be that a statin, be that Eplerenone the list is getting bigger and bigger and bigger. All of them in 20,000 people, randomized controlled trials have shown benefit to prevent heart attack, stroke, and death. And of course, if you are interested in not having a heart attack, stroke, or death again, then we would want to consider taking these tablets unless there's a very good reason not to.

But, I'm very comfortable with people, not taking, tablets. If they can adjust their risk factors with lifestyle modification, which is possible, certainly with diabetes and can be possible with cholesterol, but at the same time, you will not get your cholesterol level to the levels that you really want to, which is less than four.

And not only that, many of these medicines have unexplained benefits. The mechanisms of which we don't understand but are likely to be reduced inflammatory processes, which we know are really important in heart attacks. So my take home message to use, I don't have a disagreement with saying you should be on the minimum number of tablets that you can, you know, that you have to have.

But bear in mind, you need to control each of your risk factors. Well with evidence based medicine. But I think the best one to say, yet, you probably don't need a tablet if you can do it yourself is diabetes. And if you can lose whatever weight is required to get you to your optimum weight, then I think that is a fantastic healthcare way of avoiding diabetes drugs.

But at the same time, you will reduce your cardiovascular risk.

Paul Swindell: Absolutely. No, I wasn't saying that the patient shouldn't be taking tablets or any, evidence based medicines. I'm just saying some people sometimes need to address some easy things like their lifestyle sometimes first

Dr Tom Keeble: it's a part of the equation and you're right. Mental health, physical health and exercise are really important. Joint effort component. I think the other thing is I think we are very lucky in most of the UK that we have a pretty superb, cardiac rehab service certainly in, in Essex we have a brilliant cardiac rehab service and they do a lot of the education surrounding tablets.

And why you're taking this, because. If you find, if patients don't understand why they're taking them, then they often won't take them. Why? Why would you take something that you don't fully understand why you're taking it? But if you're very clear as to what you're taking, why you're taking and what the consequences are of not taking them and what they're trying to achieve, and in collaboration with lifestyle changes, then I think you're much more likely to be successful.

Paul Swindell: Okay. this next question is about someone who's had a auto immune diseases for many, many years and apparently they can lead to heart attacks and cardiac arrest, but without, necessarily any previous risk factors like high blood pressure or high cholesterol

Is there any evidence that supports carrying on the antiplatelet therapy for longer than a year protects the stents, if any, and the heart in general?

So yes, there is emerging evidence, and it's only one tablet. A drug called Ticagrelor. Ticagrelor is super aspirin. So, if you have a stent currently at our cardiac center, you will go home on aspirin and super aspirin, Ticagrelor which is a twice daily preparation at 90 milligrams, generally. Now the, there may be variations, there are two other drugs that we can also use. So. Please don't worry if you're on a different one. This drug was trialed in about 18,000 patients that at the end of that one year, they randomized patients to have a lower dose of Ticagrelor, versus just having aspirin alone.

So, aspirin alone versus a lower dose of super aspirin with the aspirin. And what they wanted to understand is, the problem with the super aspirin drugs that we give with stenting is that they inevitably, when you're trying to prevent clots forming, you inevitably have a downside of potential increased bleeding risk.

And many of your patients who have got these medicines and got stents will describe very much that when they shave, they have bleeding, when they knock themselves in the garden, they have big bruises. Their skin has bruises all of the time on it, and that is the nature of this beast. And so, you can imagine having a super aspirin for longer may be great for your stent, but it may be very bad for bleeding.

You could have a bleed into your tummy, you could have bleeding elsewhere, that requires medical attention. So, this trial was really important to try and understand if. The, the benefits of not running into problems with your stent and your cardiovascular system outweighed any bleeding risk. And the answer was yes.

And so absolutely in low bleeding risk patients. And what I mean by that is genuinely younger patients. You have maybe lots of disease in lots of vessels and potentially diabetes, and there were very specific criteria are likely to benefit from aspirin with a lower dose of super aspirin out to another further three years.

And that certainly what we're currently practicing at the cardiac centre and most places in the UK, because. We follow the same data. but as I said to you, if you are home and you're not on it for longer, then please do not worry. It's because your physician has decided that it's not likely that you're going to benefit.

And the decision is that there is, there were a number of criteria that we need to weigh up, but the predominant one is bleeding risk, and so if you're a high bleeding, which we would never entertain it. In fact, we want to have a short, aspirin and super aspirin, amount of, of time. So it's. The answer is yes, that some people will benefit, but it's on a case by case basis.

There is some evidence for it in certain patient groups. and your cardiologist will support that decision making.

Okay. and this person has got slightly complicated history, although it's actually quite reassuring because he had his, first cardiac arrest back in the, in the nineties or the early part of the 90s, and he had, an IC always had several ICDs, which have saved him.

And back in 2003, he had a, an MV, What's that mitral valve, implanted or, fixed. And he hasn't had a, an incident since then. So, they probably think that that was the original cause of his cardiac arrest. And the fact that he hasn't had one for 17 years now is the possibility of any further arrest now significantly reduced.

Do you think.

Dr Tom Keeble: I think it's incredibly challenging to know. I think the good thing is you rightly say is that this chaps not had one for 17 years. And so that's fantastic news, isn't it? Do you know what I mean, I think none of us have a crystal ball, it's unusual. I mean, there are some associations with mitral valve disease, which can cause cardiac arrest, and arrhythmia's and clearly that has been fixed.

You don't know. Also, at the time of that procedure may be a number of his medicines were also optimized, which may also support his, arrhythmic burden and the fact that he won't have any fear of the trouble with that. So, you know, I think that I, yeah, I, and on a case by case basis, it can be challenging to untangle everything, but it sounds like he's had a great operation to fix his valve and that these tablets are good and he's in good shape.

And I think, yeah, I think to try and untangle it any more than that can be a challenge.

Paul Swindell: Okay.

I've got a couple of questions which are related around ectopic beats, and someone asks, what are the symptoms of ectopic beats and are they anything to be worried about?

Dr Tom Keeble: Every human being on this planet has ectopics. Okay. And what an ectopic beat is, is that the top part of the heart, the atrium beats first, pumps blood into the ventricle, and then the ventricle beats and pumps blood around the body.

And what happens with a ectopic is that the ectopic doesn't have usually, or it can have an atrial beat, but it's usually a ventric ectopic where just an extra beat from the bottom part of the heart comes in. And so often what happens is, is that people feel either an extra beat or a missed beat, and it's incredibly common and people will often have it at times of stress.

People will have more often after they've had tea or coffee. Exercise generally gets rid of ectopic beans. And so look upon it. Topic beats as an extra beat, either from the top or the bottom of your heart. They are generally benign and nothing to worry about.

And what I tend to do in clinic when I see patients that describe these extra beats is do a monitoring usually for 24 hours to understand how many extra beats they have in a 24 hour period. Cause that's important.

If you're having thousands, I. E. you know, that's a lot in a 24 hour period. then we would want to consider trying to use medicine to reduce that amount of ectopics because we know that it can make the heart quite inefficient. But the vast majority of patients do not have that many.

And we'll have, you know, a hundred in a 24 hour period or 30 or so, and actually that is completely normal and is of no concern and we would do nothing about that. We would not advise medications for that. It's only if you have. Literally hundreds or thousands and are bothered by the symptoms. And once again, a beta blocker is an excellent choice of drug to suppress these extra beats, but we would only do that if they are very often and troubling the patient.

Paul Swindell: Okay.

This follow up question, which sort of touches on what you mentioned there, the why are my ectopic beats worse that they, after doing strenuous exercise, and that includes dizziness and tiredness, so they're fine during and immediately after that, the following day is awful.

Dr Tom Keeble: So, with regard to extra beats, the day after exercise, as we talked about, ectopics will usually disappear during exercise.

As the heart rate goes up, the ectopics tend to not occur so frequently usually. It's, I, I can't really explain why a whole 24 hours later you would get more of them. I don't know tha,. I don't know why.

I think if there are concerns and with any sorts of extra beats, we worry about dizziness. So if you have dizziness with that, or have concerns about extra beats, then I would seek advice from your cardiologist who will probably want to do a monitoring or monitor your ICD if you've got an ICD insight to that obviously makes life a lot easier in terms of understanding what's going on from an arrhythmia perspective. but yeah, ectopics in themselves are genuinely self-limiting and not a problem. but of course, you know that we need to tailor treatment to, to individuals from expert cardiologists.

Paul Swindell: Okay.

You touched on ICDs there. I've got a couple of questions on ICDs. I know you're not an ICD, expert, an electrophysiologist, but maybe you, maybe you can answer these.

What sorts of pains do should you expect as your ICD is healing? And what should you be concerned about?

Dr Tom Keeble: Okay, well, I think that, you know, ICD implantation is a surgical procedure, and often they put it underneath the muscle below your, your collarbone.

And so, you know, you can expect that a surgical wound is going to take at least a couple of weeks to heal and to all settle in. There's then the sort of more longer term fibrosis and really getting in a fixed position, which takes then a few more weeks thereafter. And you can imagine. If it is underneath the muscle layer and you're moving your left arm or wherever it is that the arm is closest to it, you can imagine it does take time for that sort of, that healing to happen.

Again, I think ICD patients are incredibly well followed up generally by the implanting centre and you always get a card and the number to call if you've got concerns. I think that, you know. A bit of pain for the first couple of weeks. He's absolutely to be expected, a bit of pain thereafter while it all settled in and fibrosis and gets in a nice happy position long term is to be expected, but I would always discuss it with your, ICD team and at followup, because of course the things we worry about are infection and infection can of course give you pain. So yeah.

Understand how you're feeling in other ways.

Do you have a fever?

Do you feel unwell?

Is it red?

Is it inflamed?

They are really red flag symptoms that I would want you to ring, either your doctor or your ICD team immediately. And normally ICD follow up clinics will see patients the same day if there's genuine concerns about patients. So, I think that a bit of pain is to be expected. I think if that pain is ongoing and more protracted or gets worse, that's the other thing.

Pain from a surgical procedure should get better day on day, week on week. If you noticed that it got completely better and then something new happens and it gets worse, then we would probably want to understand why that is.

We worry about redness.

We worry about infection.

We worry about the wound healing.

And so, they're really important things to, to document and to, to speak to your, team about on the number that you get given when you're discharged home.

Paul Swindell: Okay, cool.

This person was a couple of questions related to, same thing. If, if my defib or the lead is faulty, what can they do about it?

And what is the sort of procedure to rectify it?

And the second part is, is there a certain number of years after which you would not risk the removal of an ICD lead?

Dr Tom Keeble: Yeah. So, so both a good leads, you have to remember that when you put an lead in an ICD lead or any lead into the heart that's acting as a pacemaker or defibrillator, it moves a lot.

So, it will be fixed at the bottom end in the heart, in the right ventricle usually. And of course, it's fixed at the top, attached to the can and the pacemaker that does the, the pacing. And in between, there's about probably 30, 40 centimeters of lead, and this lead has to obviously be insulated. So, it's got sort of a, a coating around it.

And it also has to, move and be flexible because the hearts are very dynamic organ. And so there are two ways that the leads can become damaged. Number one is they can get fatigued over time. So from all the movement, maybe the lead moves and over five years, the, the sort of movement in the lead cause of the dynamicness of the heart causes little micro fractures in the lead, which then either stop the isolation, the, the, the coating on the outside damages that or damages the lead itself.

And we look at those parameters over time, we know exactly how much voltage is required to deliver a heartbeat to the heart. And so we can measure the impedance of the lead. And if the lead impedance is going up, we know that there may be a fault with the lead over time. So, these things can always be monitored to understand if the lead is fractured or failing.

The second thing, and this was many years ago, very occasionally, we see design fault leads and that there are recalls by companies, to say, you should really take this lead out because we don't think it's going to last. And it's faulty. And obviously that's incredibly disappointing for the company, but more over for the patient and for us as operators.

But at the same time that occasionally happens, but the common is caused is just lead failure because it's, it's run into problems because of fatigue, and as a, it's lost its ability to function properly.

Now, as you can imagine, taking a lead out that may have been in there for a number of years, can be a challenge.

We have two types of leads essentially, we have ones that are called passive fixation, and they look a little bit like an anchor, that you dropped to the bottom of the ocean. And basically you put the lead in with the anchor into the bottom of the right ventricle, and it just kind of fixes into a bit of muscle.

And over time, once it's stuck down, it will get fibrosed and it will be hard to remove. The second type of leads that we use and we're using them more and more currently are called active fixation leads. And these are want of a better term, a screw in lead, and you literally screw it into the muscle where it gets fixed.

Now you can imagine removing a screw in lead may be more straightforward because you may be able to just unscrew it and give it a little tug. And with a bit of luck it will come out. Whereas, of course, the one that has been fixed by sort of anchor technique may be really hard to pull out there. So, extraction of leads a is done by a specialist extraction team in the Essex Cardiac Centre.

We would often do it with cardiac surgery support so that if there are challenges when you pull it out and you cause some damage to the heart muscle, then you have surgical colleagues around to help you to support the patient. And that does occur in a proportion of patients, or you can just leave the lead in.

So very often because the risk of putting a lead out can be, can have significant risks associated with it. You would often just cap it off, is not going to work anymore and put a new lead alongside it that will do the job. and so there are lots of, decisions to be made as to what you do with leads and they will be made by your, your cardiologists at your center.

Paul Swindell: Okay. And, what's the sort of longest time period that, you know, the lead has been extracted?

Dr Tom Keeble: Yeah, I mean, to extract, to lead, often it will be because there's not enough space or there's infection., say often you can leave them just by the side of the other lead and the new one that you put in. I think it's difficult to know that, you know, some leads.

Yeah. The longer the lead has been in, the more difficult it is to remove, usually because it will be stuck down and fibrose. So you also have to have a really good reason to take the lead out and ensure that that's the right thing to do. And most of these decisions will go to a multidisciplinary, electrophysiology team that will decide.

Do you just put another lead in and cap off the old one? Or actually must this old lead come out? And actually, extractions are actually fleetingly rare. We don't do very many in any center in the UK because usually you can leave them be in a benign way and just put a new one next to it.

Paul Swindell: Okay.

Got a question here, which is related around,

Cardiac arrest survivors as general . why do we present such difficulties for other medical disciplines? And she's got one case he's talking about, which is, one of our members who'd had a terrible trouble with his teeth, getting them operated on. By any, anyone, I think he went all around the houses trying to find anyone who is willing to operate them. Are people just scared about how condition?

Dr Tom Keeble: Yeah, I think some of it, I think there's some naivety about your condition. Some of it, it's a bit like just having an ICD alone. A lot of people run to the Hills and don't want to do procedures on people with ICDs, but of course people with ICD still need to have tooth extractions, hip operations and other things just like anybody else.

So, I think, people can be scared because they're worried about a complication of what they do in a high risk individual, if that individual truly is high risk. but I think, as we've said before, you know, yes, cardiac arrest survivors will all have had a cardiac arrest, but in many of them, their risk of future events is modest.

And so, we need to ensure that the cardiac arrest survivors, can get the level of care they require for every type of condition, regardless of their risk.

Paul Swindell: Okay. Yes, absolutely

Paul Swindell: Well, thank you for answering all of those questions, Tom and, it's really great to talk to you again and hopefully some people have got some, anxiety release because of the answers that you've given and I hope to speak to you again soon, so if you need to take care

Dr Tom Keeble: It's an absolute pleasure.

Paul Swindell: Thanks a lot.

This concludes this episode of the Life After Cardiac Arrest podcast and I'd love to know what you think.

And you can do that via Facebook, Twitter, Instagram, or the website, and you can find this by Googling Sudden Cardiac Arrest UK or the Life After Cardiac Arrest podcast.

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Presented and edited by Paul Swindell.

Recorded April 2020. 

Why a heart attack and cardiac arrest are not equal

In episode #025 Paul talks about why a hearts attack and a cardiac arrests are not equal.

From a physiological point of view the events are quite different, a heart attack is a plumbing problem whereas a cardiac arrest is an electrical one.

Image result for heart attack cardiac arrest difference

It should be noted that both need immediate medical attention but a cardiac arrest is perhaps the ultimate medical emergency as without immediate intervention the patient will almost certainly die.

Paul talks briefly about the actual events and then lists 10 reasons why they should not be considered equal.

This is not to undermine or denigrate a heart attack, but to help the uninitiated understand what cardiac arrest survivor and their family may be going through.

For the estimated 60% that have both they may be moot points, but for remaining cohort they can make a real difference.

  1. The severities of a heart attack vs the binary nature of a cardiac arrest.
  2. State of consciousness.
  3. The need for resuscitation.
  4. Finding a cause.
  5. The care pathway.
  6. Lifestyle choices.
  7. The psychological aspect.
  8. Brain injury.
  9. Implanted devices.
  10. Insurance.

Available to listen on the link below or Spotify, Apple , Google and your favourite podcast player.

Presented by Paul Swindell and edited by Matt Nielson. Recorded November 2019